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By Donald W. Black

For many years I have pondered the mental state and motivations of mass shooters. The tragic events in Newtown, CT this past week have brought this to the fore. Mass shootings have become everyday occurrences in the United States, and for that reason tend not to attract much attention unless the circumstances are especially heinous, such as this instance in which the victims were young children. We are all left wondering what can be done. While the attention span of the general public and the media is usually a matter of nanoseconds, this mass shooting seems different, and I hope will lead to positive policy changes. This tragedy presents an opportunity for our leaders to step up to the plate and lead and, one hopes, implement rational gun control legislation most of us agree is necessary.

But back to the shooters. As a psychiatrist with an intense interest in bad behavior, I expect that discussions will center on mental health issues which many believe motivate the shooters. I am intensely interested in these “issues” because, to me, the main issue that keeps coming up is that of psychiatric diagnosis. Everyone seems interested in the possibility of a psychiatric diagnosis, because it suggests that we might “understand” the shooter, and this may lead to better identification of future shooters, and both improved treatment and prevention.

But will the presence of a psychiatric diagnosis improve our understanding? Probably not, because — at least in the cases we know about — the apparent psychiatric diagnosis runs the gamut. Some shooters appear to have schizophrenia, others a depressive disorder, and still others a personality disorder, as has been alleged in the case of Adam Lanza. While we seem able to understand that a “crazy” person out of touch with reality might carry out an otherwise senseless act, the thought that someone who is not psychotic carrying out such an act is very unsettling. How could a person who is not psychotic behave this way? For example, depressed persons are by and large not psychotic, yet some will — in the context of being hopeless and suicidal — want to take others with them: spouses, children, etc. More typically, while planning to harm themselves, most depressed persons have no desire to hurt anyone else.

What about the non-psychotic people with a personality disorder? The Diagnostic and Statistical Manual of Mental Disorders — a compendium of psychiatry’s officially recognized disorders (about to come out in its 5th edition) — lists ten personality disorders; the most relevant to our discussion is antisocial personality disorder. This disorder is quite common (up to 4.5% of the population) and causes all manner of problems because the antisocial person always seems to be in trouble with the law, their spouses and families, or their employers.

The term antisocial is almost always misunderstood and is often construed to mean ”shy” or “inhibited,” yet in a psychiatric sense the term suggests rebellion against society. My profession has done a poor job in educating the general public about the disorder and for that reason it remains under the radar screen. (An older term that seems more entrenched is sociopathy.) In the DSM, the diagnosis rests on the person having three or more of seven symptoms (such as deceitfulness, impulsivity, irritability and aggressiveness, etc). Perhaps the most important is “lack of remorse,” which occurs in about half of those diagnosed antisocial. This is what allows the antisocial person to hurt, to mistreat, or even to kill others. These are the “psychopaths” we read about and fear. (Psychopathy is at the extreme end of the antisocial spectrum of behavior.) Few antisocials are killers, but many of today’s mass shooters would fit the description of antisocial personality disorder. I don’t know if Adam Lanza would, but as we peel back the layers of his personal history, we might find that he does.

We don’t know what causes antisocial personality disorder, but like many disorders it probably results from a combination of genetic and environmental factors. I have argued for many years that the federal government needs to direct more funds to investigating its causes and developing effective treatments. Despite its high prevalence and the fact that it contributes to so much of society’s ills, the government has shown little interest in funding research on the disorder. The National Institutes of Health RePORTER website lists only two projects in which the term “antisocial” appears in the title and only five in which the terms “psychopathy” or “psychopathy” are used. Considering that NIH funds literally thousands of projects, this can only be considered hopelessly inadequate. Overcoming this resistance to research on antisocial personality disorder and related conditions must be a priority.

We need wide-ranging projects to explore the origins of antisocial behavior and search for methods to change its course. Geneticists should investigate the mechanisms underlying antisocial behavior, locating genes that might predispose individuals to antisocial behavior and determining how these genes function. Neuroscientists should pinpoint brain regions or networks linked to antisocial behavior and identify biochemical and physiological pathways that influence its expression. A range of treatments — both drugs and therapy — need to be developed, tested, and refined.

Will these steps help us understand the conundrum of the mass shooter? Will they allow us to treat antisocial persons and prevent youth with antisocial tendencies from developing a full-blown disorder? We can certainly hope.

Donald W. Black, MD is a professor of psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City. He is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy), Revised and Updated (Oxford University Press, 2013).

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When Mike Kissed Emma by Christine Marciniak. Climbing Rose Press. 2009. Personal copy.

The Plot: Emma's life is perfect. Boyfriend? Yep, she has the perfect boyfriend, Trevor. Best friend? Lauren, BFF since preschool. Family? Ok, sometimes big bro Jake can tease a bit too much and little sis Sara needs a bit of confidence, but these three like each other and hang out together. School play? Yep. OK, well, she hasn't actually gotten the role of Leisl in The Sound of Music yet -- but she's confident she'll be playing Leisl to Trevor's Rolf.

What could ruin her perfect life? Getting the lead role of Maria. Which her BFF wanted. So Lauren is mad at her. And Trevor got the role of Rolf -- opposite Sara. Somehow, Sara is mad about that. And tattooed Biker Mike got the role of Captain von Trapp, because it turns out he can sing and act (not too mention some amazing blue eyes.) She's hanging out with him, reading lines, and no one is happy with that. What's a girl to do?

The Good: As I explained on the release date for When Mike Kissed Emma, I have been friends with the author for a very long time. Not only that; but I've read all drafts of the story. To be totally honest? There is no way I can give this book an impartial review, both because of my friendship with Chris and because I know this book, I've seen it grow, like a neice or nephew. I love this book -- but I think it's only fair for you to know that connection. Wow, that is one big disclaimer / notice!

So what did I like? Other than reading the book and seeing familiar passages and noticing new things from the last time I read it? Here are the top five things I like about When Mike Kissed Emma:

1. Emma's voice. When Mike Kissed Emma is told in first person, from Emma's point of view. She starts confident -- and then realizes that what she thought was true isn't. She has to readjust how she sees things; but even with realizing that some things aren't what they seem to be, she still has confidence in herself.

2. Dialogue. Whether it's Emma talking with her friends, arguing with her siblings, turning to her mother for help, or flirting with Mike (even though she would deny that it was flirting!) the dialogue is both true to life and funny.

3. The use of the play in telling the story. On the one hand, it's about a high school play and the drama that goes on around it. It could be almost any play; and any play with a romance for Mike and Emma to play against each other and fall in love. Marciniak makes use of this particular play, The Sound of Music: the dialogue, dance scenes, songs, all are not only woven into the story but also illustrate and illuminate points along the way.

4. The cover. Covers are so important; they can make or break a book. Oh, a talented librarian or bookseller can sell the greatest book with the worst cover, but only if they have a chance to booktalk it. A cover, basically, has to booktalk a book without words. I like that it isn't a photograph; some photographs on books are too bright, too photoshoppy. Instead, we have a boy and a girl, kissing, slightly off center stage. It fits the title of the book; it's inviting; you want to pick up the book.

5. The readers as well as the characters learn a thing or two. I wouldn't be surprised if the readers come to a conclusion or two before Emma, Mike, & company. But that's good; you don't want to spoon feed it all to the reader. A book shouldn't tell them something is wrong, or right; the reader should be able to figure it out themselves.

© Elizabeth Burns of A Chair, A Fireplace & A Tea Cozy